A SURGICAL swab was left inside a patient following an operation at a Teesside hospital. 

The Northern Echo:

Members of Tuesday’s South Tees NHS board of directors heard how the error took place last week. 

The mistake – classed as a “never event” by the trust – came as plans gear up to eliminate them from happening altogether at South Tees hospitals. 

“Never events” are errors classed as “wholly preventable” – and have the potential to cause serious harm or death to a patient.

They spark investigations into why they happened and what can be done to prevent them in the future. 

The NHS lists 15 separate mistakes classed as “never events” – including performing invasive surgery on the wrong knee, eye, limb or tooth, falls from “poorly restricted windows”, and leaving “foreign objects” inside patients after surgery or invasive procedures. 

A board meeting on Tuesday heard questions about how the trust would learn from its never events – and the steps being taken to make sure they didn’t happen again. 

The panel heard how the first draft of an “improvement plan” would go before senior trust leaders next week – with an “emphasis on behavioural change” and “changing culture”.

Medical director David Chadwick said “human factors” needed addressing – while a training programme was “about a quarter of the way through” helping surgical and theatre teams.

He added: “It’s very disappointing that last week we, unfortunately, had another retained swab. 

“Lots of factors contributed to that including the wearing of PPE and one thing and another.

“But I think we’d agree there is a lot more work to be done – particularly in the operating theatres.”

Trust papers prepared for the meeting showed there have been 16 “never events” recorded at South Tees since April 2018. 

Nationally, about 30 to 50 never events are recorded every month.

But, trust leaders are aiming to stop them happening altogether as part of wider improvement plans. 

Deidre Fowler, director of nursing and midwifery, told the board how “sharing learning” and talking to other bodies who “cracked” the problem were among the trust’s aims for the future. 

She said: “There will be more emphasis on behavioural change – including human factors as well as understanding how you “mistake proof” and set people up for success.”

After the meeting, a trust spokesman said: “The delivery of safe patient care is of paramount importance to our clinicians who work tirelessly to provide the very best care day in and day out. 

“In the last year we have had more than 2.7m patient contacts across our services – and we know the vast majority have received excellent care.

“When a never event occurs we always carry out a thorough investigation of the incident to determine the cause and put in place steps to reduce any re-ocurrence.”